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Bromley B, Platt LD. First-Trimester Ultrasound Screening in Routine Obstetric Practice. Obstet Gynecol 2024; 143:730-744. [PMID: 38723258 DOI: 10.1097/aog.0000000000005594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/07/2024] [Indexed: 05/18/2024]
Abstract
Technologic advances and ultrasonographer-physician experience in fetal imaging have led to significant improvements in our ability to distinguish between normal and abnormal fetal structural development in the latter part of the first trimester. As a critical component of pregnancy care, assessment of fetal anatomy at the end of the first trimester with a standardized imaging protocol should be offered to all pregnant patients regardless of aneuploidy screening results because it has been demonstrated to identify approximately half of fetal structural malformations. Early identification of abnormalities allows focused genetic counseling, timely diagnostic testing, and subspecialist consultation. In addition, a normal ultrasound examination result offers some degree of reassurance to most patients. Use of cell-free DNA alone for aneuploidy screening while foregoing an accompanying early anatomic evaluation of the fetus will result in many anomalies that are typically detected in the first trimester not being identified until later in pregnancy, thus potentially diminishing the quality of obstetric care for pregnant individuals and possibly limiting their reproductive options, including pregnancy termination.
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Affiliation(s)
- Bryann Bromley
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, and Diagnostic Ultrasound Associates, Brookline, Massachusetts; and the Center for Fetal Medicine and Women's Ultrasound, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California
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Buskmiller C, Huntley E, Blackburn B, Sanchez D, Hernandez-Andrade E. Completion of Fetal Anatomy Evaluations in Women With Body Mass Index ≥ 50 kg/m 2. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2839-2844. [PMID: 37647313 DOI: 10.1002/jum.16323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVES As maternal body mass index (BMI) increases, fetal anatomy ultrasound becomes more challenging, less sensitive, and less likely to be complete. We sought to report our experience of incomplete evaluation of anatomy in patients with BMI of 50 kg/m2 or greater. METHODS This is a retrospective cohort of singleton gestations in mothers with BMI of 50 kg/m2 or greater, undergoing anatomy evaluations between 2017 and 2021 at 9 maternal-fetal-medicine sites in Houston, TX. Patient variables and scan results were collected throughout pregnancy to provide a longitudinal assessment of the primary outcome, completion rate (percent of all scans which optimally captured 24 American Institute of Ultrasound in Medicine-recommended images). Secondary outcomes included the rate of optimal capture of each individual structure. RESULTS In total, 293 patients with BMI ≥50 kg/m2 were identified. Only 28% of initial scans were complete, but over the entire pregnancy, a complete anatomic evaluation was achieved in 76% of women, largely due to weekly ultrasounds done for antenatal testing later in pregnancy. Neither BMI, placental location, nor amniotic fluid volume affected completion rate. The most difficult views are the outflow tracts, 4-chamber view, and spine. CONCLUSIONS One quarter of women with BMI of 50 kg/m2 or greater will not have a complete fetal anatomic evaluation by the end of pregnancy, since even basic fetal anatomic views are technically challenging to complete. Solutions deserve further attention, and may include first trimester imaging, transvaginal imaging, and optimization of ultrasound machine settings.
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Affiliation(s)
- Cara Buskmiller
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Erin Huntley
- Department of Obstetrics, Gynecology and Reproductive Sciences (UTHealth), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bonnie Blackburn
- Department of Obstetrics, Gynecology and Reproductive Sciences (UTHealth), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Darren Sanchez
- Department of Obstetrics, Gynecology and Reproductive Sciences (UTHealth), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics, Gynecology and Reproductive Sciences (UTHealth), McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Buskmiller C, Fishel Bartal M, Bonilla M, Denham C, Nguyen R, Sibai B, Pedroza C, Hernandez-Andrade E. First trimester anatomy ultrasound for patients with obesity: a randomized controlled trial. Am J Obstet Gynecol MFM 2023; 5:101143. [PMID: 37669739 DOI: 10.1016/j.ajogmf.2023.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Second-trimester ultrasound is the standard technique for fetal anatomy evaluation in the United States despite international guidelines and literature that suggest that first-trimester timing may be superior in patients with obesity. First-trimester imaging performs well in cohorts of participants with obesity. OBJECTIVE Our aim was to compare the completion rate of a first-trimester fetal anatomy ultrasound scan with that of a second-trimester fetal anatomy ultrasound scan among pregnant people with a body mass index ≥35 kg/m2. STUDY DESIGN This randomized controlled trial enrolled participants with a body mass index ≥35 kg/m2 with a singleton gestation and who presented before 14+0/7 weeks of gestation. Participants were randomized to receive an ultrasound assessment of anatomy at either 12+0/7 to 13+6/7 weeks or at 18+0/7 to 22+6/7 weeks. The primary outcome was completion rate (percentage of scans that optimally imaged all the required fetal structures). Secondary outcomes included the necessity of a transvaginal approach, completion rates for each individual view, number of anomalies identified and missed in each group, scan duration, and patient perspectives. A 1-year pilot sample was analyzed using Bayesian methods for the primary outcome with a neutral prior and frequentist analyses for the remaining outcomes. RESULTS A total of 128 participants were enrolled, and 1 withdrew consent; 62 subjects underwent a first-trimester ultrasound scan and 62 underwent a second-trimester ultrasound scan. A total of 2 participants did not attend the research visits, and 1 sought termination of pregnancy. In the first-trimester group, 66% (41/62) of ultrasound scans were completed in comparison with 53% (33/62) in the second-trimester ultrasound group (Bayesian relative risk, 1.20; 95% credible interval, 0.91-1.73). When compared with a second-trimester scan plus a follow-up ultrasound, a first-trimester ultrasound plus a second-trimester ultrasound was equally successful in completing the anatomy views (76%). First-trimester anatomy ultrasound scans required a transvaginal approach in 63% (39/62) of cases and had a longer duration than a second-trimester ultrasound scan. No anomalies were missed in either group. First-trimester ultrasound participants who responded to a survey described that they were very satisfied with the technique. CONCLUSION In pregnant subjects with a body mass index ≥35 kg/m2, a single first-trimester anatomy ultrasound scan was more likely to obtain all the recommended anatomic views than a single second-trimester ultrasound scan. An evaluation of anatomy at 12+0/7 to 13+6/7 weeks' gestation plus an evaluation at 18+0/7 to 22+6/7 led to complete anatomic evaluation 4 weeks earlier than 2 second trimester scans. Assessment of ultrasound duration in a clinical setting is needed to ensure feasibility outside of a research setting.
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Affiliation(s)
- Cara Buskmiller
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade).
| | - Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade); Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (Dr Fishel Bartal)
| | - Miguel Bonilla
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade)
| | - Chloe Denham
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade)
| | - Rachel Nguyen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade)
| | - Baha Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade)
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX (Dr Pedroza)
| | - Edgar Hernandez-Andrade
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX (Drs Buskmiller and Fishel Bartal, Mr Bonilla, Mses Denham and Nguyan, and Drs Sibai and Hernandez-Andrade)
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Capozzi VA, Rosati A, Rumolo V, Ferrari F, Gullo G, Karaman E, Karaaslan O, HacioĞlu L. Novelties of ultrasound imaging for endometrial cancer preoperative workup. Minerva Med 2020; 112:3-11. [PMID: 33205640 DOI: 10.23736/s0026-4806.20.07125-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Endometrial cancer (EC) is the most frequent gynecological cancer. Transvaginal ultrasound (TVU) plays a leading role in the preoperative workup and often is the first diagnostic instrumental examination. Despite expert hands' ultrasound is recommended to assess myometrial invasion in early stage EC, this method is a strictly operator-dependent examination, and varying degrees of sensitivity and specificity have been reported. The present review aims to provide an update of ultrasound imaging in the preoperative work-up for EC patients. EVIDENCE ACQUISITION A double-blind search was performed from May to September 2020. The following keywords: "ultrasound," "transvaginal ultrasound" and "endometrial cancer" were searched in Pubmed search engines, Scopus, and Web of Science. The Prisma statement was followed for the selection of the articles included. EVIDENCE SYNTHESIS The initial search provided 958 studies, of which 11 were included in the analysis. non-English articles, not relevant to the purposes of this study, case reports and articles with fewer than 40 cases were excluded. CONCLUSIONS TVU sensitivity and specificity in myometrial infiltration and cervical invasion is comparable to MRI but has lower costs, greater patient tolerability, and does not require contrast agents. An expert operator should perform the ultrasound examination in patients with suspected EC The presence of myometrial lesions, such as leiomyomas, could lower the diagnostic accuracy of ultrasound, so special attention should be paid to patients with concomitant uterine lesions.
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Affiliation(s)
- Vito A Capozzi
- Department of Gynecology and Obstetrics, University of Parma, Parma, Italy
| | - Andrea Rosati
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Valerio Rumolo
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Headington, Oxford, UK
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, AOOR Villa Sofia Cervello, IVF Public Center, Palermo, Italy
| | - Erbil Karaman
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey -
| | - Onur Karaaslan
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Latif HacioĞlu
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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Khaikin Y, Bishop KA, Munawar S, Pudwell J, Davies GAL. Delay of Fetal Anatomy Ultrasound Assessment Based on Maternal Body Mass Index Does Not Reduce the Rate of Inadequate Visualization. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2123-2130. [PMID: 32383804 DOI: 10.1002/jum.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/01/2020] [Accepted: 04/12/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To determine whether delay of initial anatomy ultrasound based on the maternal body mass index (BMI) reduces the rate of inadequate visualization compared to standard timing at 180/7 to 196/7 weeks. METHODS A retrospective study of singleton anatomy assessments was conducted at a tertiary care center in the 2-year period before (A, 2012-2014) and after (B, 2014-2016) protocol initiation. Assessments in period B were scheduled on the basis of the BMI in the first trimester: lower than 25 kg/m2 , 180/7 to 196/7 weeks; 25 to 29.9 kg/m2 , 190/7 to 206/7 weeks; 30 to 34.9 kg/m2 , 200/7 to 216/7 weeks; 35 to 39.9 kg/m2 , 210/7 to 226/7 weeks; and 40 kg/m2 or higher, 220/7 to 236/7 weeks. In period A, assessments were scheduled between 180/7 and 196/7 weeks. The rate of inadequate visualization and repeated assessments in periods A and B were compared. Multivariable logistic regression, per-protocol, and BMI subgroup analyses were completed. RESULTS In total, 3491 pregnancies in period A and 3672 in period B were included. In period B, 74% were scheduled per protocol; however, this rate decreased for higher-BMI categories (52% for BMI ≥40 kg/m2 ). The inadequate visualization rate was slightly higher in period B versus A (16.9% versus 15.0%; P = .03) and exceeded 35% for a BMI of 40 kg/m2 or higher, with or without delay. After adjusting for maternal age and fetal presentation, period B had small increased odds of inadequate visualization versus period A (adjusted odds ratio, 1.2; 95% confidence interval, 1.02-1.38). Repeated assessment rates were similar in periods B and A (14.0% versus 13.1%; P = .25). CONCLUSIONS In pregnancies with obesity, a protocol delaying the initial assessment beyond 196/7 weeks based on the maternal BMI does not reduce the rate of inadequate visualization.
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Affiliation(s)
- Yannay Khaikin
- Department of Obstetrics and Gynecology, Queen's University and Kingston Health Sciences Center, Kingston, Ontario, Canada
| | - Kelly A Bishop
- Department of Obstetrics and Gynecology, Queen's University and Kingston Health Sciences Center, Kingston, Ontario, Canada
| | - Saleha Munawar
- Department of Obstetrics and Gynecology, Queen's University and Kingston Health Sciences Center, Kingston, Ontario, Canada
| | - Jessica Pudwell
- Department of Obstetrics and Gynecology, Queen's University and Kingston Health Sciences Center, Kingston, Ontario, Canada
| | - Gregory A L Davies
- Department of Obstetrics and Gynecology, Queen's University and Kingston Health Sciences Center, Kingston, Ontario, Canada
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